Abstract

Objective

To compare an antiseptic solution containing chlorhexidine gluconate with povidone-iodine
for the prevention of catheter colonization and infection in critically ill patients.

Design

Randomized controlled trial.

Setting

Surgical intensive care unit (ICU) in Paris, France.

Patients

162 patients who were ≥ 18 years of age (mean age 53 y) and were scheduled to receive
a nontunneled central venous catheter or arterial catheter. Exclusion criteria were
catheter insertion for long-term total parenteral nutrition or chemotherapy, insertion
before admission to the ICU, or placement of the catheter at an existing site over
a guidewire.

Commentary

It has been estimated that every year about 50 000 patients in the United States develop
nosocomial infections related to indwelling vascular catheters, primarily central
venous and arterial catheters (1). These infections are an important problem in terms of both morbidity and health
care costs.

Povidone-iodine is a potent antiseptic agent that is widely used for skin preparation
during vascular catheter insertion and dressing changes. Mimoz and colleagues convincingly
show that, compared with povidone-iodine, a chlorhexidine-based antiseptic solution
decreased the rate of catheter colonization and catheter-related infection. Their
results reveal that the overall decrease in colonization and infection in patients
in the chlorhexidine group was caused by a reduction in the number of gram-positive
organisms. However, among patients with gram-negative isolates, more instances of
colonization and infection occurred in the chlorhexidine group than in the povidone-iodine
group. Although the latter finding was not statistically significant, the small number
of gram-negative cultures limits interpretation. Nevertheless, the predominant culprits
in catheter-related infections are gram-positive organisms, and reducing the overall
incidence of catheter-related infections is probably advantageous even if the proportion
of gram-negative infections might be somewhat increased.

Steadfast adherence to careful aseptic technique during catheter insertion, maintenance,
and manipulation can reduce, but not completely eliminate, the ever-present threat
of catheter-related infection. New developments, such as the use of silver-impregnated
subcutaneous cuffs; antibiotic-coated or antiseptic-impregnated catheters; and, as
shown by this study, improved antiseptic preparation solutions may help further reduce
this risk (2).